The challenge of costs versus quality

The NHS must produce £20billion in efficiency savings by 2014/15 yet costs are rising, with inflation alone at 5%. This puts pressure on linen services and those laundries that are controlled in-house.

At the same time external suppliers of these services are seeing their costs rise dramatically, especially those for textiles, energy and fuel and in some cases there is a need to pass on part of the rises.

The SHLSLM conference met the challenge here by inviting speakers from both sides and including managers who could advise on improving efficiency from their own experiences.

Katie Liversidge, who represented textiles supplier Whittaker Services, explained the background to the dramatic rises in the cost of cotton-based fabrics.

As a commodity, cotton accounts for 50% of all fibres used in textiles. The main producers include China, India, Pakistan and the USA.

Market pressures have been many. Cotton crops perform best in sunny, frost-free conditions with good irrigation but both Pakistan and China have had reduced crops due to flooding and frosts.

Other market influences include manipulation – slow deliveries from the harvest, capping of exports (India and Pakistan) and increased utility and labour costs.

Globally demand exceeds supply and it is a sellers’ market. The supply chain is dictating prices, bargaining power is being limited and agreed supply contracts are being broken.

Liversidge said that prices were beginning to smooth but even so predicted “more pain” before the easing and, with genuine increased demand, that easing will be limited.

The Q & A session revealed that while there are alternative fibres most need testing. Polyester, the tried and tested option is mostly blended with other fibres and is itself under cost pressures so that the gap between polyester and cotton prices is now 30% rather than 50%.

Jerry Richardson, business development director of Sunlight Services explained the cost pressures faced by external laundry service providers. Costs of textiles, utilities and transport are all rising as evidenced by the TSA laundry cost index for April.

Looking at the textile factor, he recapped briefly on the cotton situation, then put forward options.

His company was researching alternatives including 100% polyester, which was being trialled for fitted sheets and pillowcases.

Recycling damaged products by repairing them was now becoming a feasible option and was driven by the cotton crisis and certainly ticked the “green” box.

The option of buying less, however, would be difficult to sustain. Instead, said Richardson, we have to stop linen losses.

Linen loss can be permanent –- stock discarded as clinical waste, items stolen deliberately or inadvertently and linen damaged beyond repair.

Some losses though are “artificial” – stock that is not readily accessible in the circulating stock but that can be retrieved. Examples include hoarded stock or clothing left in informal locations such as the disabled toilets.

Richardson said that his company was working with customers to track down linen that disappeared when patients were discharged or died and contacting care homes and funeral parlours.

He also suggested ways of reducing loss and abuse of linen. These included identifying areas where linen goes missing, clear labelling, audits at hospitals, frequent stock takes and educating nursing staff. He suggested establishing a norm for clean to soil ratio by weighing linen in and out and physically counting linen sent in by each customer.

Putting RFID tracking on all products is advisable but the investment needed means this is not quick win.

To counteract steeply rising utility costs, Richardson suggested investing in modern technology and planned preventative maintenance. Gas use could be reduced by installing economiser boilers, modifying dryers with coated drums, using synthetic textiles and washing textiles at low temperatures.

Equipment with variable speed drives would help to reduce electricity bills as would automatic lighting.

A 35% rise in fuel costs had affected transport budgets and action here could include restricting speed, using more aero-dynamic vehicles, using larger vehicles and where possible aiming to serve only customers within a 60mile radius.

Infection control can be a contentious subject and Peter Hoffmann, consultant clinical scientist for the Health Protection Agency stressed that he was giving a personal view. His coverage of the subject was thorough and held the audience. Some of his views were controversial.

Surveys show the prevalence of disinfection is falling but that does not necessarily reflect the chances of becoming infected.

Subjects covered included the relationship between microbes and people and between microbes and infection, the difference between hospital acquired infection and community associated infection and the risks associated with the former. Most laundry is in the low risk category. Hoffman sees the main task of the healthcare launderer as removing or killing the microbes present that have adapted pathogenically so they can cause infection in hospitals.

General wash processes reduce microbes by dilution but in a healthcare application the process needs to combine dilution and disinfection as dilution is less reliable especially with processes designed to use water more efficiently.

Disinfection processes rely on either heat or chemicals but in either case quality assurance is vital. It must work 100% of the time and must be validated in real time.

Hoffman considered the pros and cons of each method but tended to the view that at present there was insufficient evidence that chemical disinfection can play a high role in quality assurance.

He also looked at the risks involved in certain areas.

He talked about the role of healthcare uniforms. Outside the surgical area, they are there for identification not protection – a sheet was more relevant to protection than a uniform and face splashes were the greatest risk for the health worker.

Controversially, he categorised nurses uniforms being washed at home as relatively low risk.

Paul Gibson, linen services manager Royal Bolton Hospitals and SHLSLM chairman looked at proposed changes in healthcare laundering guidance.

The latest development is CFPP104 which will provide a choice of frameworks for local use.

Its meaning is open to interpretation and Gibson said this was his interpretation but there could be changes in the future.

Social care

Significantly this guidance will cover social care providers as well as the healthcare sector. The essential quality requirements for social care are a domestic washer which carries an A-rated Ecolabel and which includes a 60C program. (This should not be used for infected linen). There must also be a log book, written policies and procedures and safe processes.

PPE must be available and the laundry must make the best arrangements for separating clean and dirty linen and have a clean area for storing linen, away from the laundry. The guidance notes also covered best practice in both health and social care. In addition to compliance with the minimum standard, these enhanced requirements include:

An industrial machine, which is properly installed and maintained;

A set process either for thermal disinfection at 71C or chemical- thermal disinfection. The processes must be validated.

All linen must be pre-sorted. There must be an entrance for soiled linen and clean linen must be sent out from a separate exit.

The finishing section for clean linen must be a designated area that is separate from areas used for dirty work. The airflow within the laundry must go from clean areas to dirty areas.

Gibson also discussed the viability of chemical disinfection and of laundering on site versus contracted services

Summing up the future though he remarked: ”We’re moving to black box control where machines will stop if parameters are not met.”

Alison McCree, facilities manager for County Durham and Darlington NHS Trust, gave an account of the Trust’s move from in-house to contracted-out laundry services, following a strategic review.

The old purpose-built laundry needed £1million investment over five years but was running at only 46% capacity. The Trust decided that laundry is a core service but it doesn’t have to be on site. Options included a joint partnership – within the NHS or with a commercial laundry – or outsourcing, which became the preferred option.

The Trust also decided to opt for a linen hire contract that allowed it to retain responsibility for some items, such as curtains.

Making the changeover was a complex business. A multi-disciplinary sub-group looked at key areas such as the specification and the receipt and distribution of laundered work. The group established that the laundry service would still separate clean and dirty work.

Personal concerns also had to be resolved, such as the redeployment of the old laundry’s staff to avoid redundancies. Good communication was needed as plans had to be established ahead of the laundry’s closure.

Hospital staff had to be trained to accept and handle the new regime’s procedures. This involved visits and presentations to ward sisters. Monitoring systems for the contracted service needed to be put in place.

Inevitably some problems emerged and so pressure mattresses are now handled by the Trust via a patient equipment decontamination unit.

Summing up, McCree said that the project presented several challenges particularly one of achieving savings without losing quality of service. The Trust will demand further savings on top of those already required and laundry will again be a target.

North Tees and Hartlepool Foundation Trust had also been forced to switch from an in-house service to an external provider. Linen Services manager Reg Ramsden oversaw the transition. One month before the contract started, the work was switched to another plant within the provider’s group. Teething problems were considerable. Ramsden received an average of 50 complaints a week and was making around 15 phonecalls about problems to the supplier but little happened.

A personal visit and presentation also had little effect.

Ramsden gathered monitoring tools – a camera, diary, swabbing machine and a spreadsheet to record the results. His staff were laundry trained and knew what to look for. Findings were sent to the contractor with photographic proof. Staff were encouraged to reject poor work.

Ramsden gave typical costings for that poor work. If 9 sheets are rejected from a full cage, that figure represents 3% of the load and a cost of £2.61. Based on a typical usage of 620,000 sheets, the yearly cost of that rejected work is £5,394.

Late deliveries incur not only direct costs but indirect costs of overtime. Invoice discrepancies add-up.

Getting results

Monitoring brings results. Now complaints about linen have fallen to just two per week with the same number of phonecalls to the supplier.

Communication has improved. Work is now being sent to a different plant, phone calls about problems do lead to action, meetings also produced reasonable results. “You can influence service quality,”advised Ramsden. “Prove your case by emailing photos of poor work to the supplier.”

His advised linen managers to check and keep checking – work, deliveries, invoices, every aspect. Make sure that the contract includes penalties. Never relax your guard.

As a former NHS laundry manager, who is the SHLSLM national officer and also an independent consultant, Ian Hargreaves knows both sides of arguments over costs versus quality.

The NHS budget pressures mean savings must be made. Who pays for those savings?

When all aspects of a linen service have been squeezed what’s next? Linen usage was his prediction but how can this be achieved?

To find answers, ask questions. Consider different answers. Clients need to be informed about costs. Who knows what the item cost is in a linen service? Certainly ward staff do not know such details.

There needs to be a balance between a very low level of use that can harm patients and compromise hygiene and a level that is so high it becomes wasteful.

Hargreaves explained the reasons for both. Reasons for low use include not enough stock, increased demand, bed changes dependent on staff numbers and attempts to reduce spends.

High usage stems from wards with insufficient buffer stock, fears that linen won’t be replaced if it isn’t used, rigid bed change policies that ignore the possibility that a change might not be needed, being supplied with sub-standard linen, transfer to linen hire and access to increased stock.

Providing more information can be one way to tackle the problem and produce more sensible usage.

Hargreaves produced case study evidence of the improvements achieved when staff were shown information about costs. They were given leaflets that encouraged them to think more about whether linen needed to be replaced.

Reporting savings

There were weekly reports to wards about projected savings and importantly staff knew that the savings made would be re-invested.

The results of such efforts can produce a reduction in use of between 33.75 to 43.75% with a savings per bed of between £346 and £473 per year.

As facilities manager at the Royal Oldham Hospital, Steven Moss is responsible for one of the largest NHS run laundries in the North West. He pointed out that although NHS funding is ringfenced that doesn’t take account of rising costs and inflation alone will bring increases of 5%.

Royal Oldham is part of the Pennine Acute Hospital Trust, which must save £45million in 2011/12 and has announced that it wants to shed 1,000 jobs including compulsory redundancies.

Yet costs are rising all round, with inflation affecting drug costs in particular. Moss faces marked rises in both his departments. The Health Service Cost index for January showed that laundry contract charges had risen by 3.89% and transport fuel by 15.33 while in April the TSA Laundry Cost index showed a 14.9% rise in overall linen service costs.

With such pressures how do you meet the demand for steep savings?

Moss raised some possible areas where savings might be made. In transport these included reducing delivery frequencies (but more storage will be needed); looking at vehicle sizes, examining distances and routes.

Areas to look at in linen service included checking whether the uniform service is cost-effective; asking relatives to wash patients’ clothing at home and looking for ways to reduce linen losses. Moss also suggested some sources of advice. The Energy Saving Trust had produced The Green Fleet review (a case study showing savings to be made in fleets of 50 or more vehicles).

Useful advice

The Carbon Trust has useful advice for laundries, for example it says that drying moisture costs five times as much as squeezing it out. The Trust also has figures for energy targets by laundry type. For example, a small OPL might aim for 3 – 3.6kwh per kg of linen while a modern plant processing over 400,000 items per week should reduce use to 1.3 – 1.6kwH/kg.

Labour costs can be reduced by increasing the number of pieces processed per operator hour, by dispensing with services no longer required , reducing overtime and enhanced working.

Finally Moss summed up by quoting the rule for successful business. “ Never tell them everything you know”.